func%onal gastrointes%nal disease pediatrics
TRANSCRIPT
Func%onalGastrointes%nalDiseasePediatrics
SmallGroupSession:March1,2020ChristopheFaure,MD,Professor
DivisionofGastroenterology,HepatologyandNutriCon,UniversitédeMontréal(CHUSainte-JusCne)
ElyanneRatcliffe,MD,AssociateProfessorDivisionofGastroenterologyandNutriCon,McMasterUniversity
(McMasterChildren’sHospital)
Conflict of Interest Disclosure (over the past 24 months)
• NorelevantrelaConshipswithanycommercialornon-profitorganizaCons
Name: Dr. C. Faure
Conflict of Interest Disclosure (over the past 24 months)
Commercial or Non-Profit Interest Relationship
American Neurogastroenterology and Motility Society
Member, ANMS Council
Name: Dr. E. Ratcliffe
✔ Medical Expert (as Medical Experts, physicians integrate all of the CanMEDS Roles, applying medical knowledge, clinical skills, and professional values in their provision of high-quality and safe patient-centered care. Medical Expert is the central physician Role in the CanMEDS Framework and defines the physician’s clinical scope of practice.)
✔ Communicator (as Communicators, physicians form relationships with patients and their families that facilitate the gathering and sharing of essential information for effective health care.)
✔ Collaborator (as Collaborators, physicians work effectively with other health care professionals to provide safe, high-quality, patient-centred care.)
Leader (as Leaders, physicians engage with others to contribute to a vision of a high-quality health care system and take responsibility for the delivery of excellent patient care through their activities as clinicians, administrators, scholars, or teachers.)
✔ Health Advocate (as Health Advocates, physicians contribute their expertise and influence as they work with communities or patient populations to improve health. They work with those they serve to determine and understand needs, speak on behalf of others when required, and support the mobilization of resources to effect change.)
✔ Scholar (as Scholars, physicians demonstrate a lifelong commitment to excellence in practice through continuous learning and by teaching others, evaluating evidence, and contributing to scholarship.)
Professional (as Professionals, physicians are committed to the health and well-being of individual patients and society through ethical practice, high personal standards of behaviour, accountability to the profession and society, physician-led regulation, and maintenance of personal health.)
CanMEDS Roles Covered
LearningObjecCvesAttheendofthissessionparCcipantswillbeableto:1. RecognizetheconCnuumofclinicalpresentaConsoffuncConal
consCpaConandirritablebowelsyndromeinpediatricpaCents.2. IdenCfypsychosocialfactorsthatplayaroleinthegenesis/
exacerbaConofpediatricIBS.3. Describemanagementapproaches,bothpharmacologicandnon-
pharmacologic,usedinthecareofpediatricpaCentswithIBS.
Case• 12yearoldfemale• Referredfor“consCpaCon”• 2yearhistory
• Abdominalpain• VomiCng• ConsCpaCon
Case• MulCpleadmissionsfor“consCpaCon”presenCngwithabdominalpainandvomiCng
• NGinserted;cleanoutwithPEG+electrolytes• Dailybowelmovements;BristolType6• DecreasedappeCte;feels“full”• Abdominalpaindayandnight;moderate4-7onpainscale
Does she have func-onal cons-pa-on or IBS with cons-pa-on?
FuncConalConsCpaConRomeIVDiagnos%cCriteriaforFunc%onalCons%pa%on(Child/Adolescent)
Mustinclude2ormoreofthefollowingoccurringatleastonceperweekforaminimumof1monthwithinsufficientcriteriaforadiagnosisofirritablebowelsyndrome
1. 2orfewerdefecaConsinthetoiletperweekinachildofadevelopmentalageofatleast4years
2. Atleast1episodeoffecalinconCnenceperweek3. HistoryofretenCveposturingorexcessivevoliConalstool
retenCon4. Historyofpainfulorhardbowelmovements5. Presenceoflargefecalmassintherectum6. Historyoflargediameterstoolsthatcanobstructthetoilet
AherappropriateevaluaCon,thesymptomscannotbefullyexplainedbyanothermedicalcondiCon.
HyamsJSGastroenterology2016
IBS–PartofFBDConCnuum
Lacy BE Gastroenterology 2016
IrritableBowelSyndromeRomeIVDiagnos%cCriteriaforIrritableBowelSyndrome(Child/Adolescent)
Mustincludeallofthefollowing:
1. Abdominalpainatleast4dayspermonthassociatedwithoneormoreofthefollowing:a. RelatedtodefecaConb. Achangeinfrequencyofstoolc. Achangeinform(appearance)ofstool
2. InchildrenwithconsCpaCon,thepaindoesnotresolvewithresoluConofconsCpaCon(childreninwhomthepainresolveshavefuncConalconsCpaCon)
3. AherappropriateevaluaCon,thesymptomscannotbefullyexplainedbyanothermedicalcondiCon.
Criteriafulfilledforatleast2monthsbeforediagnosis.
HyamsJSGastroenterology2016
PrevalenceofFGIDsaccordingtoRomeIV
RobinetalJPediatr2018
Case• AddiConalsymptomsofheadaches,blurredvision,dizziness,weaknesses
• Parentsseparated;familystressedbyadmissions/appointmentsandlackofprogress
• DuetoconstellaConofsymptomsandprominenceofabdominalpain–referredtoPediatricChronicPainProgram
Should we worried be about anything else?
ClinicalAssessment• EstablishaworkingandtherapeuCcalliancewithpaCentandfamily• TakeCme+++• PaCent’shistory• Painhistory• StressfullepisodeorinfecCousepisodeassociatedwithonsetofsymptoms
• PsychosocialhistoryofpaCentandfamily• FamilyhistoryofGIdisorders• DietaryassociaConwithpainepisodes
RedFlags:neithersensiCvenorspecific…• Pain
! NocturnalPain! Persistantrightupperorrightlowerquadrantpain
• AssociatedGIsymptoms! PersistentvomiCng! Nocturnaldiarrhea! Dysphagia! Hematochezia! Perirectaldisease
• Generalsymptoms! Fever,arthriCs,apthousulcers! InvoluntaryWeightloss! DeceleraConoflineargrowth,delayedpuberty
• FamilyhistoryofIBD
• Familyhistoryofceliacdisease• FamilyhistoryofpepCculcer
RasquinetalGastroenterology2006
…butthegreaterthenumberpresent,thegreaterthelikelihoodoforganicdisease
Work-Up?• DirectedbyhistoryofthechildandfamilyandbyphysicalexaminaCon• IniCalscreeningcaninclude:
• CBC,CRP,albumin• IgAtTG• ALT,lipase/amylase• Urianalysis• FecalcalprotecCn• Stoolforovaandparasites
IBSandCeliacDiseaseIBS:4Cmeshigherriskofhavingceliacdiseasethanthe
generalpediatricpopulaCon(P<.001;oddsraCo,4.19[95%CI,2.03-8.49])
CristoforietalJAMAPediatr2014
What caused her to be like this?
FBD–SensiCzingEvents
HyamsJSGastroenterology2016
Post-infecCousFGID• Norovirus:Nopediatricdata
• IBS(OR11.40;95%CI3.44–37.82;Zaninietal.AmJGastroenterol2012),
• FD,consCpaCon(Porteretal.ClinInfectDis2012)
• Giardia:• IBSRR=3.4(95%CI2.9to3.8)aherinfecCon(Wensaasetal.Gut2012)
• Diarrhea,flatulenceinpreschoolchildren(Mellingenetal.BMCPublicHealth2010)
• CJejuni(IBS,FD)• Salmonella(IBS,FD)• Shigella(IBS)
Spilleretal.Gastro2009Sapsetal.JPediatr2008Futagamietal.APT2015
But she is not an anxious girl…
VisceralHypersensiCvityandSymptomSeverity
• PsychologicalcomorbidityiscommoninFGIDs• BarostattesCnginadultIBSandFDcohortsdemonstratedincreasingGIsymptomseveritywithincreasingvisceralhypersensiCvity
• Findingswereindependentofatendencytoreportsymptoms,oranxiety/depressioncomorbidiCes
Simrénetal,Gut.2018Feb;67(2):255-262
VisceralHypersensitvity:RectalSensoryThresholdforPain(RSTP)
IBS Controls0
10
20
30
40
50
RST
P (m
mH
g)
FaureetalJPediatr2007CasCllouxetalJPGN2008
IBS Controls0
10
20
30
40
50R
STP
(mm
Hg)
85% of the pa-ents = RSTP ≤ 30.8 mmHg
(<5th perc. of Normal Children)
Psychologicalco-morbidiCesarefrequent
IBS FAP FD50
60
70
80
90
100STAI-C
CampoetalPediatrics2004FaureetalJPediatr2007CasCllouxetalJPGN2008
Anxiety~50% Depression~10%IBS FAP FD
0
10
20
30
40
CDI
Family-childdynamicsinfluenceseverityofsymptoms
FamilyFactors• Modeling• Psychologicaldistress• ParentalpercepConof:
• Pain• Child’sself-efficacy
• ParentalprotecCveness(e.g.keepinghomefromschoolwhenchildinpain)
• Parentalcatastrophizing
ChildFactors
• Copingstyle/self-efficacy
vanTilburgetal,WorldJGastroenterol2015;21(18):5532-41DuPennetal,Children2016;3(15)
Cunninghametal,JPGN2014;59:732–738
So, how do we treat this?
Treatmentshouldbetailoredto…
• IBSsubtype:IBS-D,IBS-C• IBSseverity• Associatedpsychologicalco-morbidiCes• IBSpathophysiologicalmechanism(?)
ManagementofFGIDs
• PosiCvediagnosis• ProvidepathophysiologicalexplanaCons• Reassurance
• Symptomsarerealbutarenotlife-threatening• Mustlearntolive/copewiththesymptom
• Avoidtriggers
IBSTreatment:NutriCon• Reducesorbitol,fructose,lactose?• LowFODMAPs• Fibres=age(years)+5g• Avoid:
• Fat• Tea,coffee,Coke• Spicyandacidicfood
IBS:SymptomaCcTreatments• ConsCpaCon:mineraloil,lactulose,PEG3350• Diarrhea:loperamide(Imodium®),cholestyramine(Questran®)…
• Pain:AnCspasmodics:trimebuCne,dicyclomine,Pepermintoil(KlineJPediatr2001)…
• Gas:simethicone…
IBS:Non-pharmacologicalTreatments
• ProbioCcs:LactobacillusGG,LactobacillusrhamnosusGGJPGN2010;51:24-30Gut2010;59:325-32
• HypnosisVliegeretal.Gastroenterology2007
• CogniCvebehaviouraltherapy(CBT)Youssefetal.JPGN2004
IBS:TreatmentofSevereFormsInmostseverecases(schoolabsenteeism)• Amitriptyline0.2to0.4mg/kgHS,10to50mg/day;or
• Imipramine0.2to0.4mg/kgHS,10to50mg/day(lessanCcholinergic)
• Citalopram(5-HTreuptakeinhibitor)10mg/dayto40mgdie
• Mirtazapine7.5to15mgHS
Baharetal.JPediatr2008(RCT)Sapsetal.Gastroenterology2009(RCT)
TeitelbaumJPGN2011(Open)Campoetal.2004(openstudy)RoohafzaetalNGM2014RCT
Hussainetal.JPGN2014
CheckforSuicidalIdeaConandQT
Placebo
Kaptchuketal.BMJ2010
TheplaceboeffectinIBS(evenwhenplaceboisannounced)
What’snext?• IBS-C:LinacloCde:Guanylate-cylaseCagonist
• ImprovesvisceralhypersensiCvity;increaseschloridesecreCon• IBS-D:Eluxadoline:mu-opioidreceptoragonistandadelta-opioidreceptorantagonist
• IBS-D:Ondansetron:5-HT3Rantagonist• LarazoCde:sCmulaConofCghtjuncCons• EbasCne(Aerius)(H1antagonist):TRPV1desensibilisaCon(Wouters2016)• Pregabaline(SaitoetalAPT2018)• And…understandwhysomepaCentsrespondtoFODMAPSandothersdonot
AuricularNeurosCmulaConControls ac-vity of pain areas in the central nervous system par-cularly the amygdala and spinal cord
IB-STIM™
KrasaelapetalClinGastroHepatol2020KovacicetalLancetGastro2017
27IBSadolescents(medianage,15.3y):auricularneurosCmulaCon23IBSadolescents(medianage,15.6y):shamsCmulaCon5days/weekfor4weeks
%with30%improvementinworstpainseverityinPENFSvsshamaher3weeksandatextendedfollow-up8–12weeksaherendoftherapy
MoayyediPJCAG2019HyamsJSGastroenterology2016
IBSManagement-Pediatrics
Linaclotide: Safety and efficacy study of a range of doses administered orally to children aged 7-17 years, with irritable bowel syndrome with constipation (NCT02559817). Study completion date August 2019. Black box warming for < 6 years.